Insurance Verification and Benefits form

Your Name *

Type your first and last name as it appears on your insurance card.

First Name

Last Name

Your Date of Birth *

MM

DD

YYYY

Pay Source *

BCBS

United

UMR

Aetna

Health Choice

Other

Subscribers Name *

Type the first and last name of the subscriber.

First Name

Last Name

Subscribers Date of Birth *

MM

DD

YYYY

How are you related to the insured subscriber: *

Self

Spouse

Child

Other

Benefits & Eligible Services *

Please select the appropriate box if you are eligible for the following services

CPT: 90837 Individual Therapy

CPT: 90847 Family Therapy with Client Present

CPT: 90846 Family Therapy without Client Present

CPT: 90839 Crisis Intervention

CPT: 90853 Group Therapy

My Plan Covers Teletherapy

My Plan Covers Medical Neccesity